DCS or dehydration? What call to make

[IWantToBeAFish]

Hi all,

I recently heard a story from a customer about their recent experience. Location was tropical waters, reasonably remote (3 hours to chamber) in SE Asia.

After an unchallenging 18m dive, when boarding the boat they felt a stiffening pain in their leg, became dizzy and confused and needed a lot of help to get up the ladder. (He had been fine on the dive).

Their instructor decided to play it safe, lay them down and administered O2 on return to dive shop while calling ahead about it. I suspect the treatment scared the customer a little and it sounds as if he became more despondent on the return.

Back at shore, the manager was waiting with more water and to help and they assisted him to the dive shop. They treated him for shock and dehydration as they started to realise he had not had much to drink that day at all and had already dived in the morning. An hour later he was fine.

It has me wondering:
- Did they make the right call?
- Was it ambiguous enough to call DAN?
- With an evacuation potentially very expensive and the customer having no travel insurance (student backpacker), would this influence your decision?
- With symptoms occurring almost immediately after surfacing, would you rule out DCS?
- Would the presence of confusion and dizziness cause you to suspect AGE?

While dehydration seems likely, being that it is also a significant case of DCS, should they have got him somewhere for longer monitoring anyway? Thankfully I've yet to deal with a real potential DCI situation while working and it has me concerned about making the right call. I suppose if in doubt, DAN is always there.

Thanks in advance for your thoughts and opinions.

 

[TSandM]

Certainly, severe dehydration can result in lightheadedness or even fainting in an upright position, especially when going from the support of the water to a ladder. However, the mild dehydration that's generally seen from warm weather and inadequate intake shouldn't do that in a healthy person. (If the person in question had been ill with some kind of tropical gastrointestinal distress with vomiting and diarrhea, that could be distinctly different, but someone would be ill-advised to dive in that condition.)

In my personal opinion, if symptoms of weakness and disequilibrium occur after a dive, especially with exertion (as in climbing the ladder), I would assume this was DCS until clearly proven otherwise. Many DCS cases will improve on oxygen, but the patient may relapse or even experience worse symptoms after the oxygen is withdrawn.

 

[Mr Carcharodon]

- Did they make the right call? [By the right call you mean putting him on oxygen? Sure why not? Oxygen is cheap. The rub comes when expensive treatments are proposed for vanishingly small probabilities of illness]
- Was it ambiguous enough to call DAN? [Why would you not? They are free, knowledgeable and accessible, clearly something odd had happened. Maybe AGE, but gathering information, or asking DAN what to ask would make sense]
- With an evacuation potentially very expensive and the customer having no travel insurance (student backpacker), would this influence your decision? [Of course it does. What world do you live in Mr Rockefeller?]
- With symptoms occurring almost immediately after surfacing, would you rule out DCS? [for single dives of typical recreational duration to 18m probably yes]
- Would the presence of confusion and dizziness cause you to suspect AGE? [Maybe. Does the dive profile or information from the diver support this? DAN statistics suggest that AGE is far more common than DCS for recreational dives]
While dehydration seems likely, being that it is also a significant case of DCS [short of going thousands of minutes past NDL there is no support for this whatsoever. Inert gasses are very poorly soluble in water and a half a liter, or a liter of water, more or less does not significantly drive gas load so try to focus of depth, time and mix which are known to matter rather than old wives tales]

 

[Martigan]

While dehydration seems likely, being that it is also a significant case of DCS [short of going thousands of minutes past NDL there is no support for this whatsoever. Inert gasses are very poorly soluble in water and a half a liter, or a liter of water, more or less does not significantly drive gas load so try to focus of depth, time and mix which are known to matter rather than old wives tales]

I strongly disagree with this assertion. The added water does not indeed result in significant added gas load, but it does increase DCS probability.
Less water induces a higher viscosity of blood, and it has a negative impact on gas exchange at the pulmonary level, and also on the surface tension when dealing with micro bubbles of gas in the blood.
When diving there are already many diuretic phenomenon (such as cold, pressure on legs and arms, very dry air in the tank etc), you should not add classical dehydratation to the mix, especially in warm countries.

 

[The Chairman]

Having had low blood pressure most of my life (it's been pretty normal as of late), I found that diving and not drinking enough water could cause serious cramps. I still come up half way up a ladder and hold on a bit while my body adjusts to the pressure difference. Low blood sugar can do this as well.

Disclaimer: I am not a medical doctor. I fix sick Networks and not people. This is merely my personal experience with this.

 

[openmindOW]

. . . felt a stiffening pain in their leg, became dizzy and confused and needed a lot of help to get up the ladder. It has me wondering:
- Did they make the right call?
- Was it ambiguous enough to call DAN?
- With an evacuation potentially very expensive and the customer having no travel insurance (student backpacker), would this influence your decision?
- With symptoms occurring almost immediately after surfacing, would you rule out DCS?
- Would the presence of confusion and dizziness cause you to suspect AGE?

I am NOT a doctor. I defer to the medical doctors on SB.

Having said that, I'll venture my ignorant lay opinion.

Pain in the leg? Sounds serious to me.

Why not call DAN?

Cost? Well, what's the cost of long-term disability?

 

[Quero]

I'm only going to opine on this small bit of the post:

- With an evacuation potentially very expensive and the customer having no travel insurance (student backpacker), would this influence your decision?

It would NOT influence my decision in the least. I work in a part of the world where there are many, many backpacking divers, and these divers come from a variety of countries. Some of these countries have national health and accident insurance which would cover treatment and evac, so I wouldn't simply assume that because the diver doesn't have much spending money and hasn't purchased travel insurance s/he has no insurance to fall back on. Furthermore, if the diver is a student, s/he may very well still be protected under a parent's health/accident insurance plan.

BTW, just in case divers show up with no coverage at all, I have registered with DiveMaster Insurance in the UK, which offers daily cover for very affordable rates.

 

[DevonDiver]

How did the victim respond to O2 provision?

Were their symptoms assessed properly using a rapid/5-min neuro-check, with regular re-assessment? If so, how did the symptoms progress (and respond to the O2)?

- Did they make the right call?

Administering O2, fluids and treating for shock... yes.

Not suggesting further medical treatment/diagnosis/confimation of all-clear.... no.

- Was it ambiguous enough to call DAN?

I'd suggest calling DAN for any suspicion of DCS.

- With an evacuation potentially very expensive and the customer having no travel insurance (student backpacker), would this influence your decision?

No.

- With symptoms occurring almost immediately after surfacing, would you rule out DCS?

No.

- Would the presence of confusion and dizziness cause you to suspect AGE?

The job of first responders is to provide first aid. First aid for DCI/AGE is the same... that's why we treat for "DCS". Don't confuse first-aid with diagnosis - that's a job for medical professionals. It seems in this instance that staff attempted to diagnose...and that was a mistake.

Every dive pro knows the format for DCI first-aid. That protocol always ends with "evacuate to medical care". Why was that protocol not followed through to the end?

 

[TSandM]

By the way, I do want to make an observation here. In the US, the person's state of insurance or lack of it would not affect any decisions to treat. Treatment would be offered, and the bills settled up later. I have heard stories that it is not that way in other parts of the world, and that if you cannot show insurance or put up a bond, treatment will be denied.

I think there are some profiles where you can say with almost total certainty that the patient's symptoms are not DCS -- the people who talk about symptoms after pool dives, or open water class dives to 20 feet, fall into that category. There are some profiles where you can say that DCS is overwhelmingly likely. But in the middle are a group of profiles where you may think the likelihood is low -- but for example, in this case, we don't know how many dives this person had done that day, or that week, so we don't know the total nitrogen loading at all. That does affect how one might think about the symptoms.

 

[billt4sf]

After an unchallenging 18m dive, when boarding the boat they felt a stiffening pain in their leg, became dizzy and confused and needed a lot of help to get up the ladder. (He had been fine on the dive).

Couldn't the symptoms also be due to AGE? (Symptoms similar to a stroke).

Just asking.....